The pending removal from the market of one of the most abused prescription drugs in Canada could make the tragedy of under-treated pain worse and lead to other unintended consequences for which we aren't prepared.

Starting Thursday, the manufacturer of OxyContin — the prescription pain reliever known as "Hillbilly heroin" for its ability to produce a heroin-like hit when snorted or injected — is phasing out the drug and replacing with OxyNEO, a reformulated version that its maker says is harder to crush or liquefy.

Six provinces have almost simultaneously announced plans to restrict access to OxyNEO.

Leaders in the pain community are calling that move a misguided and emotional response that could lead to unforeseen fallout — such as a run on emergency services for people going into withdrawal, or wider prescribing of less-controlled but potentially more harmful opioids. Some of those opioids are as much as six times more powerful than morphine.

The controversy is exposing deep divisions in the medical community. Some doctors say the limits being imposed on a drug dispensed 1.6 million times in 2010 alone can't come soon enough. Dr. David Juurlink said opioids in general, and long-acting oxycodone (the active ingredient in OxyContin) in particular, are being prescribed at dangerously high doses and often for long periods of time, without good evidence from randomized, controlled trials that the benefits of such a practice outweigh the risks.

Restricting access isn't likely to make a meaningful dent in the problem of opioid abuse, said Juurlink, head of clinical pharmacology at Sunnybrook Health Sciences Centre in Toronto.

What it will do, he predicted, is lead to fewer prescriptions for long-acting oxycodone.

What doctors have been taught about the prescribing of opioids such as oxycodone has come largely from pharmaceutical companies and doctors paid to speak on their behalf, Juurlink said, "and what we've been taught is wrong."

Although some chronic pain patients clearly do benefit, "there are also a number of patients who do not," he said.

By some estimates, more than 100,000 North Americans have died in the past 25 years as a result of prescription opioids, he said. Juurlink is blunt: "An awful lot of people have died because of our willingness to prescribe opioids for chronic pain."

"As a doctor, I don't want to see people suffering or in pain," he said. "But we simply are not using these drugs properly."

Opioids slow the transmission of pain signals to the brain. They also alter the sensation of pain. They produce, on average, about a 30 per cent reduction in chronic-pain intensity. Their side effects include nausea, dizziness, sedation, constipation and fatigue, and new research has started linking their long-term use with osteoporosis and immune-suppressing effects.

Today, Canadians are among the highest users of prescription opioids in the world. In the past decade alone, our opioid consumption has more than doubled, and the biggest increases have been for the heavy-hitters, including oxycodone (which is one-and-a-half to two times more potent than morphine) and hydromorphone (five to six times more potent than morphine), according to a recent study by British Columbia and Ontario researchers.

Among the provinces, Alberta had the overall highest opioid use rate in the country in 2010, Quebec the lowest — but nowhere are the rates falling. Prescriptions for oxycodone are increasing in all provinces. According to Ontario's Health Ministry, between 300 and 400 people die each year in the province from opioid-related overdoses and that the opioid most frequently found during autopsies in recent years is oxycodone.

Overall, in 2010, Canadian pharmacies filled just over 17 million prescriptions for opioid analgesics, according to IMS Brogan, a prescription drug-research firm; 9.4 per cent of those prescriptions — 1,618,000 — were for OxyContin.

Health Canada has announced it will gradually discontinue funding of the drug for First Nations patients.

Meanwhile, Saskatchewan, Ontario, Nova Scotia, New Brunswick, Prince Edward Island and Newfoundland and Labrador have all announced new restrictions on coverage of OxyNEO.

In Ontario, the drug will be funded through the "exceptional access program." Doctors will have to submit requests on a case-by-case basis, providing all relevant medical information as well as the "clinical rationale" for requesting the unlisted drug.

"Essentially they're saying, we're going to restrict access to this new formulation that we're all praying and hoping is less abusable but doctors can still prescribe these other more potent alternatives without these restrictions," says Dr. Roman Jovey, a past president of the Canadian Pain Society.

Putting any medication on EAP creates a huge barrier to its use because of the paperwork and "hassle factor" involved for doctors, he said. The average time to process a request in Ontario is currently three months.

"Can you imagine what will happen in a year from now when they receive tens of thousands of extra requests due to the OxyNEO issue?" Jovey said.

"This is going to create anxiety. It's going to create panic in some cases. There are going to be huge delays and the only people to be harmed by it will be people in pain legitimately using the drug."

Jovey said he is not opposed reducing the amount of opioids being prescribed. "But you have to offer something else and right now physical treatments (for pain) aren't funded, psychological treatments aren't funded.

"How do you expect physicians who are faced day-to-day with folks sitting across their desk saying, 'I really hurt.' How do you expect them to reduce their prescribing? The prescription pad is one of the few tools that we have."

Other pain doctors worry that family doctors will jump to more potent opioids more quickly than they otherwise would, or that patients who aren't getting their pain controlled will overuse over-the-counter pain medications in doses high enough to damage their livers or cause gastro-intestinal bleeding.

But Juurlink says an aggressive approach is needed.

In a study published last year, he and his colleagues at the Institute for Clinical Evaluative Sciences in Toronto examined trends in opioid use and dosing among social assistance recipients in Ontario.

They found that prescriptions rose 16 per cent between 2003 and 2008. By 2008, one-third of beneficiaries receiving long-acting oxycodone were getting between 200 and 400 mg of morphine equivalent per day, in excess of national guidelines; 15 per cent were taking "very high doses" — more than 400 mg of morphine equivalent per day.

The risk of death from any cause was about tenfold higher in people on very high doses of the drugs.

Doctors "need to ease up on the prescribing of these drugs," Juurlink maintains, "and anyone who suggests otherwise is wrong."

Most prescribing is well intentioned, he said. "Doctors don't want their patients in pain. I myself have sometimes prescribed opioids for chronic, non-cancer pain." But he said opioids are self-perpetuating.

Problems arise, he said, when the pain is reduced only slightly, "and so the doctor increases the dose, and the pain is perhaps reduced a little bit more, but then the patient is physically dependent on the drug.

"We shouldn't be resorting to opioids as readily as we are. We should not be escalating doses as rapidly as we are, and we should be abandoning opioids if they are not very clearly reducing the pain a patient is experiencing," Juurlink said.

Dr. Norm Buckley agrees that some patients are getting higher-than-necessary doses. Much of the OxyContin that's being abused is being diverted from legitimate prescriptions and by patients deluding doctors into thinking that they need the medication, said Buckley, professor and chair of the department of anesthesia at McMaster University in Hamilton, Ont.

Still, "relatively small numbers of our patients come in with the intent to deceive us," said Buckley, who has been participating in discussions with pharmacists, law-enforcement officials and others, led by the Canadian Centre on Substance Abuse, toward development of a national strategy to reduce prescription drug abuse and diversion.

"Most of our patients come in with a problem," he said. "But we don't treat pain very well at the best of times."

There is poor access to pain clinics, partly because there are not enough physicians trained in pain management, he said, "so it's difficult to get access to somebody who actually knows anything about pain."

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